OFFICE OF THE EXECUTIVE SECRETARY

Supreme Court of Virginia

APPLICATION FOR MEDIATION COURSE CERTIFICATION

Please use black ink so this document will be legible when scanned.

Applications for course certification must be submitted at least thirty (30) days in advance of the training date. DRS will review applications within thirty (30) calendar days of receipt. Please note that extra time should be allotted beyond the thirty (30) days for the applicant to make any changes/revisions that may be necessary.

This application will be considered pursuant to certification criteria established by the Judicial Council of Virginia and without regard to race, color, religion, political affiliation, national origin, handicap, sex or age.

SECTION I PROGRAM INFORMATION (Please type or print.)

1.  Name and mailing address of person responsible for the training program ______

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Telephone: ______Email: ______

Fax: ______

2.  This application is for certification of a:

a.  _____ 20-Hr. Basic g. _____ 4-Hr. VA Judicial

b.  _____ 20-Hr. Family h. _____ 8-Hr. Domestic Abuse

c.  _____ 40-Hr. Family i. _____ 4-Hr. Mentoring Others

d.  _____ 20-Hr.Circuit-Civil j. _____ 8-Hr. Observation (Specify if class is for,

e.  _____ 12-Hr.Circuit-Family GDC, J&DR, CCC or CCF certification)

f. _____ Other (Specify number of hours and subject matter) ______

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3.  Name(s), mediator certification number(s), certification type(s), and last recertification date of

trainer(s) seeking certification. [Attach resume(s)]

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4.  Mediation training of trainer(s) seeking certification (beyond that needed to certify; please submit supporting documentation).

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5. Education of trainer(s) seeking certification.

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6.  Mediation experience of trainer(s) seeking certification (please submit supporting documentation.

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7.  Adult Education experience of trainer(s) seeking certification.

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8. Has the training program been presented before? Yes _____ No ____ If so:

a. Number of times this training program has been presented ______

b. Number of participants in most recent presentation ______

c. Attach evaluations of the program by the participants in the most recent presentation.

9.  a. Minimum number of participants for this course ______

Maximum number of participants for this course ______

10.  Number of experienced mediators who will observe, process, and critique the role plays ______

Ratio of trainees to observers ______Names and certification level of observers. If not, describe method of selection for the observers.)

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11.  Names and certification level of training assistants

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12.  Names and experience of subject matter specialists

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SECTION II GENERAL COURSE INFORMATION

1.  Please describe the objectives of the training program ______

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2. Please describe the format of the program and give approximate time spent on the following: lecture,

discussion, exercises, and role plays ______

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3. Please attach a copy of the course agenda, outline, manual, and any additional materials that would be helpful in evaluating the course.

SECTION III SPECIFIC COURSE INFORMATION

REQUIREMENTS FOR EACH COURSE TYPE (Please refer to attached course outlines. These lists are not exclusive.)

On a separate piece of paper:

a.  give a brief description of how the course covers each of the subjects listed in the Course Outline;

b.  identify the areas in your attached agenda/course outline that correspond to each subject; and

c.  identify the approximate time spent on each of the subjects.

SECTION IV BACKGROUND

1. Have you ever been convicted of a felony, a misdemeanor (includes reckless and aggressive driving), a traffic violation resulting in suspension or revocation of a driver’s license, or a DUI/DWI? Conviction includes guilty or nolo contendere pleas. Yes _____ No _____ If Yes, list on the lines provided below (please include the specific code section(s) violated).

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  1. Have you ever 1) had a disciplinary action related to a profession, including mediation (for example, a professional license suspended or revoked); 2) had any professional privileges curtailed; and/or 3) relinquished a professional privilege or license while under investigation?

Yes _____ No _____ If Yes, describe on the lines provided below.

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3.  If you answered “Yes” to question #1 or #2 above, please describe the impact, if any, this could have on your ability to provide mediation training.

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SECTION V CERTIFICATION

I understand that information regarding this course may be provided to individuals seeking training by the Office of the Executive Secretary.

I hereby certify that the information provided in this application is true to the best of my knowledge. I understand that all information herein is subject to verification and that the training may be observed at any time by a representative of the Office of the Executive Secretary as a part of the certification process.

I hereby certify that I have read the Standards of Ethics and Professional Responsibility for Certified Mediators adopted by the Judicial Council of Virginia effective July 1, 2011, and that the course described herein will provide training in accordance with these Standards.

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Signature of Person Responsible for Providing Training Date

A $25.00 check or money order must accompany this application. Please make check payable to the Treasurer of Virginia. Do not send cash.

Please forward this application and check to:

Dispute Resolution Services

Office of the Executive Secretary

Supreme Court of Virginia

100 N. Ninth Street, Third Floor

Richmond, VA 23219

If you have any questions or comments, please contact

Dispute Resolution Services at 804-786-6455.

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FORM ADR-2000

August 2014